1. Breast cancer stats
-1 in 8 women who live to 85 will get it
-3.4% lifetime risk of death
2. NSABP B04 trial: role of radical mastectomy. Among patients with clinically node negative (i.e. no palpable nodes, because this was done in an era before scans) there was no difference in survival between those who got radical mastectomy (breast, pec major, entire axillary contents) and those who got simple mastectomy +/- node radiation.
3. Clinically node-negative: 30% will still have cancer in their nodes; clinically node-positive (i.e. palpable nodes) 70% will have cancer in their nodes, since frequently caused by things like inflammation, particularly after a biopsy
4. What actually kills you in breast cancer is mets (brain, bone, adrenals, lung, liver), and so by the time most of these breast cancers were detected in the early days, it was already too late for surgical resection to make a difference thus it is thought why no survival difference between radical and simple mastectomy.
5. NSABP B06 trial: role of breast conservation. Compared modified radical mastectomy to lumpectomy and ALND +/- radiation. No difference in survival between breast-losing and breast-conserving therapy, but the addition of radiation significantly decreased likelihood of local recurrence-- which many decades later was shown to be associated with increased survival, but the effect was subtle, visible only in the long-term and with high-power: {Lancet}
6. Options for tissue diagnosis of breast cancer:
-FNA: tells you limited information, essentially cancer vs non-cancer. Good to r/o the possibility of cancer/reassure someone when they are young, healthy, and 99% likely to have a fibroadenoma but are anxious and want a biopsy
-Core needle: standard for diagnosis. Gives you enough tissue for histology, grading, receptors-- HER, ER, etc.
-Incisional: biopsy of skin-- i.e. peau d'orange for inflammatory breast cancer, or a weird looking nipple looking for pagets
-Excisional: rarely done, because we rarely go to OR without tissue diagnosis. Often because you went to the OR to excise what you thought was a benign mass (ductal papilloma) but later happened to find DCIS in the sample.
7. Options for breast cancer surgery: mastectomy (+/- immediate reconstruction) or lumpectomy; if you get lumpectomy, you HAVE to get radiation.
8. Absolute contraindications for breast-conserving surgery:
-Inability to get radiation-- i.e. previous chest/mantle radiation for hodgkin's
-Multi-centric diagnosis-- 2+ cancers in different quadrants.
-Diffuse malignancy with microcalcifications-- will make future tracking of progression difficult to impossible.
-Persistent positive margins after multiple (1-2x) reasonable attempts at surgical resection.
9. Relative contraindications for breast-conserving surgery: 
-Large tumor size relative to breast size
-Pregnancy, particularly in the 1st and 3rd trimester. Radiation is CI in pregnancy, chemo is not.
-Collagen vascular diseases? Increased risk of late-complications? Maybe, maybe not.
10. Things that are NOT contraindications to breast-conserving therapy:
-Lymph node +/-: the breast surgery is independent of the axillary surgery. You can still do ALND
-Location in breast
-Family history, genetic mutations
-Aggressiveness of cancer, risk of systemic relapse